Discover the clinical approach to the integrative care model for OUD to improve treatment adherence and recovery for those in need.

Abstract

Welcome to this educational exploration of Opioid Use Disorder (OUD). My name is Dr. Alex Jimenez, and I am a Doctor of Chiropractic, Advanced Practice Registered Nurse, and a Board-Certified Family Nurse Practitioner with certifications in functional and integrative medicine. In this post, we will embark on a comprehensive journey to understand the multifaceted nature of OUD. We will begin by tracing the historical arc of opioids, from their ancient origins to the development of powerful synthetic agents that have defined the modern opioid crisis. We will then examine the powerful roles of stigma and myth, which continue to create significant barriers to effective care, and I will share strategies, such as person-first language, to dismantle them. A central focus of this discussion will be the evidence-based treatment recommendations, grounded in the latest research from leading experts in the field. I will provide a detailed overview of both pharmacological interventions—such as methadone, buprenorphine, and naltrexone—and non-pharmacological approaches, including motivational interviewing and harm reduction strategies. Importantly, I will explain how our multidisciplinary team at Injury Medical Clinic PA integrates these advanced treatments. We will explore how integrative chiropractic care complements medical and functional medicine protocols, addressing the musculoskeletal and neurological components of pain and recovery that are often intertwined with OUD. This post aims to provide a clear, empathetic, and scientifically robust resource for patients, families, and fellow healthcare professionals, showcasing a holistic path toward healing and long-term recovery.

Our Multidisciplinary Approach at Injury Medical Clinic PA

At Injury Medical Clinic PA in El Paso, Texas, we have cultivated a unique and powerful healthcare model designed to address complex conditions like Opioid Use Disorder (OUD) from multiple angles. Our clinic is built on integrative, multidisciplinary care, where specialists collaborate to create a truly holistic treatment plan for each patient.

Dr. Maria Guadalupe Cardenas, MD, leads our medical team as our esteemed Medical Director and Collaborative Physician. Dr. Cardenas is Board Certified in Internal Medicine and brings over four decades of invaluable experience to our practice. Her extensive expertise (NPI #1164426749, Texas MD License #J2933) in managing complex medical conditions provides the essential medical oversight that anchors our clinical operations. Her role is to ensure that all medical interventions, including pharmacological treatments for OUD, are safe, appropriate, and aligned with the highest standards of care.

As a practitioner with dual licensure as a Doctor of Chiropractic (DC) and a Family Nurse Practitioner (FNP-BC), I, Dr. Alex Jimenez, work closely with Dr. Cardenas. This partnership allows us to blend different care philosophies seamlessly. My chiropractic background focuses on the body’s structure, particularly the spine, and its relationship to nervous system function and overall health. As a nurse practitioner, I am trained to diagnose and treat illnesses, prescribe medications, and manage patient care from a primary care and functional medicine perspective.

This synergistic collaboration is the cornerstone of our practice. Here is how our team integrates various services:

• Medical Oversight and Pharmacotherapy (Dr. Cardenas and Dr. Jimenez): Cardenas provides the top-level medical direction, while my FNP credentials allow me to manage the day-to-day pharmacological aspects of OUD treatment, such as prescribing medications like buprenorphine, under our collaborative agreement. We work together to monitor patient progress, manage side effects, and adjust treatment plans as needed.
• Integrative Chiropractic Care (Dr. Jimenez): Many individuals with OUD initially began using opioids for chronic pain. My role as a chiropractor is to address the underlying musculoskeletal issues that contribute to this pain. Through spinal adjustments, soft tissue therapies, and corrective exercises, we aim to improve biomechanics, reduce nerve irritation, and decrease reliance on pain medication. This is not just an adjunctive therapy; it is a core component of our strategy to treat the root cause of the patient’s physical suffering.
• Functional Medicine (Dr. Jimenez): We go beyond symptom management by using functional medicine to investigate the root biochemical and physiological imbalances contributing to a patient’s condition. This involves advanced lab testing to assess nutritional deficiencies, gut health, hormonal imbalances, and inflammation levels—all of which can impact mood, cravings, and the ability to recover. We then create personalized nutrition and lifestyle protocols to support brain chemistry and overall physiological resilience.
• Rehabilitation and Personal Injury Care: Our clinic is also equipped to handle comprehensive rehabilitation for patients who have sustained injuries, which are often the genesis of chronic pain and subsequent opioid use. We integrate physical therapy, chiropractic care, and medical management to facilitate a full recovery, helping patients regain function and reduce the need for long-term opioid therapy.

By weaving these disciplines together, we offer a patient-centered “whole person” approach. A patient at our clinic is not just receiving a prescription; they are receiving a coordinated care plan that addresses their medical, structural, biochemical, and lifestyle needs, providing a robust and supportive pathway to lasting recovery.

The Long and Winding History of Opioids

To truly grasp the complexities of the current opioid crisis, we must first travel back in time and understand the origins and evolution of these powerful substances. The story of opioids is a long one, marked by medical breakthroughs, societal shifts, and unforeseen consequences.

From Ancient Poppies to Modern Synthetics

The journey begins with the opium poppy plant, Papaver somniferum. It is from this plant that we derive a class of substances known as opiates, or natural opioids.

• Natural Opioids (Opiates): These are alkaloids derived directly from the resin of the opium poppy. The two most well-known are morphine and codeine. They have been used for centuries for their potent analgesic (pain-relieving) and euphoric properties.
• Semi-Synthetic Opioids: These substances are created in a laboratory by chemically modifying natural opiates. This category includes some of the most commonly prescribed and misused opioids today, such as heroin (synthesized from morphine), oxycodone, and hydrocodone.
• Synthetic Opioids: These are entirely manufactured in laboratories and are not derived from the opium plant at all. They are designed to act on the same opioid receptors in the brain as natural opiates. This group includes medications like methadone and the notoriously potent fentanyl.

A Timeline of Discovery and Development

The chronological development of these substances reveals a pattern of increasing potency and accessibility, which has directly contributed to the public health emergency we face today.

• 3400 BC: The earliest recorded cultivation of the opium poppy is found in Mesopotamia. Ancient civilizations, including the Greeks and Romans, recognized its medicinal value and used it as a powerful pain reliever. By the 1400s and 1500s, it was also being used to treat conditions like diarrhea.
• 1803: A pivotal moment occurs when morphine is first extracted from opium. This allowed standardized dosing and more targeted medical use, revolutionizing pain management.
• 1832: Codeine is isolated from opium and quickly becomes a common ingredient in cough suppressants.
• 1874: In an attempt to create a less addictive alternative to morphine, chemists synthesize heroin. Ironically, it was initially marketed as a non-addictive morphine substitute and cough suppressant.
• 1939: During World War II, German scientists searching for a synthetic painkiller that could be produced domestically developed methadone.
• 1959: Fentanyl is first synthesized. This synthetic opioid is estimated to be 50 to 100 times more potent than morphine, and its development marked a significant leap in opioid potency.
• 1966: Buprenorphine is discovered. As a partial agonist, its unique properties would later make it a cornerstone of modern OUD treatment.

As you can see, many of the substances at the heart of our current crisis were developed within the last 200 years, with their widespread use and subsequent misuse escalating dramatically in recent decades.

Understanding Potency: Morphine Milligram Equivalents (MME)

When we discuss different opioids, it is crucial to understand their relative potencies. We use a standardized measure called Morphine Milligram Equivalents (MME) to compare them. This allows us to gauge the potential risk of different opioids by converting their dosages to an equivalent dose of morphine.

Here is a look at several common opioids, listed in order of increasing potency:

• Tramadol:1 MME (meaning 10 mg of tramadol is equivalent to 1 mg of morphine)
• Codeine:15 MME
• Hydrocodone:0 MME (a 1:1 ratio with morphine)
• Oxycodone:5 MME (50% more potent than morphine)
• Hydromorphone:0 MME (4 times more potent than morphine)
• Fentanyl (Transdermal Patch):4 MME per microgram/hour. This conversion can be complex, but it highlights the extreme potency of fentanyl. A small amount of fentanyl can have the same effect as a much larger dose of morphine, which is why it is so dangerous, especially when it contaminates the illicit drug supply.

Understanding MME is not just an academic exercise. As clinicians, we use this to assess the risk of overdose in our patients. Higher daily MME totals are strongly correlated with an increased risk of respiratory depression and fatal overdose.

The Three Waves of the American Opioid Crisis

The United States has experienced the opioid crisis in three distinct, devastating waves, each characterized by a different primary substance and a tragic escalation in overdose deaths.

Wave 1: Prescription Opioids (1999–2010)

The first wave began in the late 1990s, fueled by a perfect storm of factors. Pharmaceutical companies aggressively marketed new formulations of prescription opioids, such as OxyContin, while downplaying their addictive potential. At the same time, a cultural shift in medicine emphasized treating pain as the “fifth vital sign.” This led to a massive increase in the prescribing of opioid painkillers.

• The Impact: Between 1999 and 2010, sales of prescription opioids in the U.S. quadrupled. As prescribing rates soared, so did misuse and overdose deaths. During this period, the rate of opioid-involved overdose deaths doubled, rising from 2.9 to 6.8 deaths per 100,000 people. Many individuals who developed a substance use disorder during this time did so after being legally prescribed opioids for legitimate pain.

Wave 2: The Rise of Heroin (2010–2013)

As awareness of the prescription opioid problem grew, efforts were made to crack down on “pill mills” and reformulate drugs to make them harder to abuse. While well-intentioned, this had an unintended consequence. As prescription opioids became more expensive and harder to obtain, many individuals who had developed a physical dependence turned to a cheaper and more readily available alternative: heroin.

• The Impact: From 2010 to 2013, heroin-related overdose deaths surged, increasing from 1.0 to 4.9 per 100,000 people. During this period, for the first time, deaths from heroin surpassed those from prescription opioids.

Wave 3: The Scourge of Synthetic Opioids (2013–Present)

The third and most lethal wave began around 2013 with the infiltration of illicitly manufactured synthetic opioids, primarily fentanyl and its analogs, into the drug supply. Fentanyl is incredibly potent and cheap to produce, making it profitable for drug traffickers to mix it into other drugs like heroin, cocaine, and counterfeit prescription pills, often without the user’s knowledge.

• The Impact: The results have been catastrophic. Over just five years, the death rate from synthetic opioids increased by over 1,000%, skyrocketing from 1.0 to 11.4 deaths per 100,000 people. This wave is responsible for the dramatic spike in overdose deaths we have seen in recent years. We have also seen the emergence of other dangerous substances, such as the non-opioid sedative xylazine (also known as “tranq”), which is increasingly found in fentanyl-related overdose cases, complicating treatment and rescue efforts.

In response to this escalating tragedy, the U.S. Department of Health and Human Services officially declared the opioid crisis a public health emergency in 2017, a declaration that remains in effect. The graph from the Centers for Disease Control and Prevention (CDC) below visually demonstrates the terrifying progression of these three waves, with the purple line representing synthetic opioids showing a nearly vertical climb since 2013.

The Current Landscape of Opioid Misuse

Data from the 2021 SAMHSA National Survey on Drug Use and Health provides a sobering snapshot of the scale of this issue. Among people aged 12 or older in the United States:

• 2 million people reported misusing opioids in the past year.
• Of those, approximately 1 million misused prescription pain relievers only.
• About 1 million people used heroin, with roughly half a million using heroin exclusively and the other half using both heroin and prescription pain relievers.

These numbers underscore a critical point: while heroin and fentanyl dominate the headlines about overdose deaths, the misuse of prescription pain relievers remains a massive problem. As clinicians, this reminds us of our profound responsibility to screen our patients, prescribe judiciously, and offer support and treatment when misuse is identified.

Key Legislation and Treatment Milestones

The legal and regulatory landscape surrounding opioids has evolved significantly over the last century, reflecting society’s changing understanding of addiction and treatment.

• Harrison Narcotics Tax Act (1914): One of the first major federal laws to regulate opioids. It criminalized the non-medical use of opiates and laid the groundwork for a punitive, rather than a public health, approach to substance use.
• Controlled Substances Act (1970): This act established the drug scheduling system (Schedules I-V) that we still use today and created the Drug Enforcement Administration (DEA) to regulate controlled substances.
• Narcotic Addiction Treatment Act (1974): This legislation designated that methadone treatment programs must be federally regulated and certified, creating the structured “methadone clinic” system.
• Drug Addiction Treatment Act of 2000 (DATA 2000): This landmark legislation created the “X-waiver.” For the first time, it allowed qualified physicians to prescribe buprenorphine—a safer, partial-agonist opioid—in an office-based setting, moving treatment out of the confines of specialized clinics and into mainstream medicine.
• Comprehensive Addiction and Recovery Act (CARA) of 2016: This act expanded the authority to prescribe buprenorphine to Nurse Practitioners (NPs) and Physician Assistants (PAs), significantly increasing the number of providers who could offer this life-saving treatment.
• SUPPORT for Patients and Communities Act (2018): This bipartisan legislation expanded access to OUD treatment within Medicare and Medicaid, helping to remove financial barriers for many patients.
• Mainstreaming Addiction Treatment (MAT) Act of 2023: In a monumental step forward, this act eliminated the X-waiver requirement. This means that any prescriber with a standard DEA license who is permitted to prescribe Schedule III medications under their state license can now prescribe buprenorphine for OUD. This has been a game-changer, removing a major administrative barrier and further integrating OUD treatment into routine medical care.

The Rationale for Treatment: Combating Myths and Stigma

Despite overwhelming evidence of its effectiveness, treatment for Opioid Use Disorder is still tragically underutilized. Understanding why requires us to confront the powerful and persistent myths and stigma that surround this disease.

The Stark Reality of the Treatment Gap

The statistics are staggering. In the United States, of the roughly 9 million adults who need treatment for OUD, only a little over 2 million (about 22%) actually receive medications for opioid use disorder (MOUD). This is a massive treatment gap for a disease that is both treatable and fatal if left untreated.

• Annual Impact: In 2022 alone, there were nearly 82,000 opioid-related overdose deaths. The economic toll is equally immense, estimated at over $193 billion annually in healthcare costs, lost productivity, and criminal justice expenses.
• Disparities in Care: Treatment access is not equal. The demographics most likely to receive MOUD are white males between the ages of 35 and 49, highlighting significant disparities that need to be addressed.

These figures paint a clear picture: OUD is a devastating chronic disease that we are failing to treat on a systemic level. A major reason for this failure is stigma.

Debunking Common Myths About OUD Treatment

To effectively treat OUD, we must first arm ourselves and our patients with facts to counter the harmful myths that perpetuate stigma.

• Myth 1: “Medications for OUD just replace one addiction with another.”

• • Fact: This is perhaps the most damaging myth. Let’s reframe this using an analogy from another chronic disease: diabetes. We would never say that giving insulin to a person with Type 1 diabetes is “replacing one dependency with another.” Insulin is a life-saving medication that corrects a physiological imbalance. Similarly, medications like buprenorphine and methadone work by stabilizing brain chemistry that has been dysregulated by long-term opioid use. They reduce cravings and withdrawal symptoms, allowing the individual to stop the chaotic cycle of illicit drug use and focus on rebuilding their life. This is medical treatment, not a substitute for addiction.

• Myth 2: “Recovery without medication is a superior or ‘truer’ form of recovery.”

• • Fact: This creates a false hierarchy of recovery that is deeply stigmatizing. Consider two patients with hypertension. Both are advised to improve their diet and exercise. One patient successfully lowers their blood pressure with lifestyle changes alone. The other still has high blood pressure and needs to add medication. Would we ever say the first patient’s treatment plan was “superior”? Of course not. They are simply two different individuals with different physiological needs. The same is true for OUD. The goal is to help the patient achieve stability and health. For many, MOUD is the most effective tool to achieve that goal. The evidence is clear: MOUD has been shown to reduce mortality by up to 60%.

• Myth 3: “Medications for OUD are not effective.”

• • Fact: This is patently false. Decades of research have demonstrated that MOUD is the gold standard of care. They significantly reduce the risk of overdose, decrease illicit opioid use, reduce the transmission of infectious diseases like HIV and Hepatitis C, and improve social functioning and retention in treatment.

• Myth 4: “People who need medication to stop using are just weak-willed.”

• • Fact: This myth ignores the fundamental neuroscience of addiction. OUD is a chronic brain disease. Prolonged opioid use physically changes the brain’s structure and function, particularly in the areas responsible for reward, decision-making, and impulse control. This is not a matter of moral failing or a lack of willpower. It is a physiological hijacking of the brain’s executive functions. MOUD helps to correct these neurobiological changes, giving the individual the ability to regain control.

What is a Substance Use Disorder? A Clinical Perspective

To move beyond stigma, we must embrace the modern medical understanding of substance use disorders. In the past, you may have heard terms like “abuse,” “dependence,” or “addiction.” Today, the clinical standard, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), is the term Substance Use Disorder (SUD).

SUDs are classified as chronic, relapsing medical conditions that affect the brain. Clinicians diagnose SUDs using a specific set of 11 criteria and categorize severity (mild, moderate, or severe) based on how many criteria the individual meets. The good news is that, like other chronic diseases, SUDs are treatable with evidence-based interventions.

The DSM-5 Criteria for Opioid Use Disorder

An individual must meet at least two of the following criteria within a 12-month period to be diagnosed with OUD. Notice how many of these criteria relate to behavior and life impact, rather than just the quantity of the substance used.

1. Impaired Control:

• • Taking the opioid in larger amounts or over a longer period than was intended.
  • A persistent desire or unsuccessful efforts to cut down or control opioid use.
  • Spending a great deal of time in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  • Craving, or a strong desire or urge to use opioids.

• Social Impairment:

• • Recurrent opioid use failing to fulfill major role obligations at work, school, or home.
  • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use.

• Risky Use:

• • Recurrent opioid use in situations in which it is physically hazardous (e.g., driving while impaired).
  • Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

• Pharmacological Criteria:

• • Tolerance: A need for markedly increased amounts of the opioid to achieve intoxication or desired effect, OR a markedly diminished effect with continued use of the same amount.
  • Withdrawal: Experiencing the characteristic opioid withdrawal syndrome, OR taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.

It is crucial to note that meeting only the pharmacological criteria (tolerance and withdrawal) in the context of appropriate medical treatment for pain does not constitute an OUD. The patient must also meet at least one of the other behavioral criteria.

The Pervasive Impact of Stigma on Care

Stigma is not just an abstract concept; it is a tangible barrier that prevents people from seeking and receiving life-saving care. It manifests at every level of society.

Public and Structural Stigma

• Public Stigma: This is the prejudice within the general community. It often involves the refusal to see SUD as a chronic medical condition, leading people to associate OUD with crime and moral weakness. This mindset leads to opposition to public health policies that increase access to treatment, such as harm reduction centers or supportive housing. Some studies suggest this stigma intensifies with age.
• Structural Stigma: This occurs when stigma is embedded in institutions and policies. The “War on Drugs,” declared in 1971, is a prime example. It framed substance use as a criminal issue, not a health issue, leading to mass incarceration (disproportionately affecting racial and ethnic minorities) with very little access to treatment within the justice system. The historical X-waiver itself was a form of structural stigma; it required extra training and paperwork to prescribe a life-saving medication (buprenorphine) while no such hurdles existed for prescribing the very opioids that were fueling the crisis. Lack of funding for treatment and discriminatory drug testing policies for housing and employment are other examples.

Individual and Provider Bias

• Individual Stigma: This includes the stereotypes, prejudice, and discrimination directed at individuals with OUD. People with OUD are often unfairly stereotyped as dangerous or unpredictable. This can lead to discrimination, such as coercive treatment (“If you use again, I will stop treating you”) or social exclusion. This also leads to internalized shame, where the individual begins to believe these negative stereotypes about themselves, thinking they are “less than” or not worthy of help.
• Provider Bias: Unfortunately, stigma is also present among healthcare providers. Studies have shown higher levels of bias in rural areas and among providers who view SUD as a moral failing rather than a medical disease. Providers may also worry about the legal or regulatory scrutiny of treating this patient population. The dangerous consequence of this bias is a reduced likelihood of prescribing MOUD, even when it is clearly indicated.

The Power of Language: Adopting a Person-First Approach

One of the most immediate and powerful ways we can begin to dismantle stigma is by changing the language we use. Person-first language is a simple but profound shift that reorients our thinking. It emphasizes the individual’s humanity rather than defining them by their disease.

Here are some practical examples:

Avoid Stigmatizing Language	Use Person-First Language	Rationale
Addict, user, junkie	Person with a substance use disorder, person in recovery	The person is not their disease. This separates the individual from their condition.
Abuser, injector	Person who uses drugs (PWUD), person who injects drugs (PWID)	“Abuse” is a judgmental term associated with harm and violence. “Misuse” or “use” are more neutral, objective descriptors of behavior.
Born addicted, crack baby	Baby with neonatal opioid withdrawal syndrome (NOWS)	A baby cannot be “addicted” as addiction involves compulsive behaviors. A baby can, however, experience physiological withdrawal from in utero exposure.
Clean vs. Dirty (urine test)	Negative for [substance] vs. Positive for [substance]	Would we call the blood of a person with high blood sugar “dirty”? No. This language is shaming and judgmental. We should use objective, clinical terms.
Medication-Assisted Treatment (MAT)	Medications for Opioid Use Disorder (MOUD)	The word “assisted” implies that medication is just a helper, secondary to the “real” treatment. Medication is the treatment, a core intervention.
Abuse	Misuse or Use	Again, this removes the pejorative and judgmental connotations associated with the word “abuse.”

Putting it into Practice: A Case Study Transformation

Let’s revisit a hypothetical case study, first with stigmatizing language and then revised with a person-first approach.

Original (Stigmatizing) Version:

“Substance use history: Patient reports abusing heroin IV from age 20 to 30. Last used one month ago after 7 years clean. Treatment history: Entered recovery after an overdose. Started medication-assisted treatment. Strengths: Regularly involved with the addict community. Family history: Father is an OUD addict in recovery. Child: Has a 9-year-old daughter who was born addicted to heroin.

Revised (Person-First) Version:

“Substance use history: The patient reports misusing heroin IV from ages 20 to 30. Her last use was one month ago after seven years of no use. Treatment history: She entered recovery after an overdose and started medications for opioid use disorder (MOUD). Strengths: She is regularly involved with the recovery community. Family history: Her father has a history of OUD and has been in recovery for 30 years. Child: She has a 9-year-old daughter who was born with neonatal opioid withdrawal syndrome (NOWS) and is healthy now.

Do you feel the difference? The second version is respectful, objective, and non-judgmental. It describes the situation without defining her by it. This is the language of compassionate, effective care.

Evidence-Based Treatments: The Path to Recovery

Now, let’s turn to the practical, evidence-based strategies we use to help our patients on their recovery journey. This involves a combination of behavioral therapies, pharmacological treatments, and harm reduction techniques.

Motivational Interviewing: Partnering with the Patient for Change

Motivational Interviewing (MI) is more than a communication technique; it is a collaborative, goal-oriented style of communication designed to strengthen a person’s own motivation for and commitment to a specific change. It is particularly effective for individuals with OUD, as it puts them in the driver’s seat of their own recovery.

The Spirit of MI

The philosophy of MI is built on four pillars:

1. Partnership: You and the patient are collaborators. Your role is to be supportive, not persuasive. You are walking alongside them, not dragging them forward.
2. Evocation: The motivation for change must come from the patient. Your job is to evoke their own perceptions, goals, and values, not to impose your own.
3. Acceptance: This involves recognizing the patient’s absolute worth, honoring their autonomy (their right to make their own choices), affirming their strengths, and practicing deep empathy.
4. Compassion: You must remain nonjudgmental, non-blaming, andnon-judgmental This is essential for building the trust needed for a therapeutic relationship, especially with a population that frequently encounters judgment.

The Process of MI: Engaging, Focusing, Evoking, and Planning

MI follows a structured process to guide the conversation:

1. Engaging: First, you must establish a good rapport and a strong therapeutic relationship.
2. Focusing: Together with the patient, you identify a specific, patient-centered goal. What does the patient want to change?
3. Evoking: This is the heart of MI. You explore the patient’s own motivation for change. Why is this goal important to them? What are their reasons for wanting to change?
4. Planning: Once the motivation is clear, you work together to create a concrete plan of action, identifying specific steps, exploring options, and building a support system.

Core MI Skills: OARS and DARN-CATS

MI provides practical acronyms to help structure conversations.

OARS represents the core communication skills:

• Open-ended questions: “Can you tell me a little bit about your recovery journey?”
• Affirmations: “That’s a really creative idea for how to avoid situations where you might be tempted to use.”
• Reflective listening: This involves reflecting what the patient says, often rephrased, to show you are listening and deepen the conversation. In good MI, you should be doing more reflecting than questioning.
• Summaries: “Let me make sure I understand. You’re saying that… Is that correct?” This ensures mutual understanding.

DARN-CATS helps you elicit “change talk”—statements from the patient that favor change.

• Desire: “What do you hope our work together will accomplish?”
• Ability: “What do you think you might be able to change about your opioid use?”
• Reasons: “What are some of your reasons for wanting to stop or cut back?” (e.g., “I want to be there for my child’s graduation.”)
• Need: “What needs to happen for you to feel ready to make this change?”
• Commitment: “I want to…”
• Activation: “I am ready to…”
• Taking Steps: “I have already started attending meetings.”

By listening for this type of language, you can gauge the patient’s readiness for change and tailor your approach accordingly.

Understanding the Stages of Change

MI works in concert with the Transtheoretical Model of Change, which outlines five stages a person goes through when making a behavioral change. Identifying a patient’s stage is crucial for meeting them where they are.

1. Pre-contemplation: The person is not considering change. (“I don’t think my drug use is a problem.”)
2. Contemplation: The person is ambivalent about change, weighing the pros and cons. (“I think my marriage would improve if I reduced my drug use.”)
3. Preparation: The person is committed to change and is planning to take action soon. (“I’ve looked up an NA meeting to attend near my house.”)
4. Action: The person is actively taking steps to change their behavior. (“I’ve reduced the number of days per week I use drugs.”)
5. Maintenance: The person is working to sustain the change and prevent relapse. (“I have been on medications for opioid use disorder for a year now.”)

As clinicians, our role is to help the patient move from one stage to the next, not to force them into action before they are ready.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

Non-Pharmacological Management and Support

While medications are a cornerstone of treatment, they are most effective when combined with behavioral support and community.

• Behavioral Therapy: This can include one-on-one counseling with a psychologist, social worker, or a certified recovery coach. These professionals can provide structured therapies like Cognitive Behavioral Therapy (CBT) to help individuals identify and change negative thought patterns and behaviors.
• Group Support: Mutual support groups provide a powerful sense of community and shared experience. There are many different models:

• • Narcotics Anonymous (NA) / Alcoholics Anonymous (AA): These are 12-step programs that often incorporate a spiritual or “higher power” component.
  • SMART Recovery (Self-Management and Recovery Training): A secular, science-based program that uses principles from CBT and Rational Emotive Behavior Therapy (REBT).
  • Secular Organizations for Sobriety (SOS): This offers another non-religious alternative for group support.

It is vital to remember that participation in these groups, while highly encouraged, should never be a requirement for a patient to receive MOUD. Many meetings are open to healthcare providers to observe, and I encourage my fellow clinicians to attend one to understand better the resources you are recommending to your patients.

The Role of Integrative Chiropractic Care in Recovery

At our clinic, we have observed that addressing the physical body is a critical, often overlooked, component of recovery from OUD. Many of our patients first turned to opioids to manage chronic pain, often stemming from musculoskeletal injuries or chronic postural stress.

How Chiropractic Care Fits In:

• Addressing the Root of Pain: Instead of just masking pain with medication, chiropractic care aims to correct the underlying structural and neurological issues causing it. Through spinal adjustments (spinal manipulative therapy), we work to restore proper motion to restricted spinal joints. This can reduce pressure on nerves, decrease inflammation, and alleviate pain signals that drive the desire for opioids.
• Neurological Regulation: The nervous system is the body’s master controller. Spinal misalignments, or subluxations, can interfere with communication between the brain and the body, contributing to chronic stress and dysregulation known as dysautonomia. Chiropractic adjustments can help calm the sympathetic “fight-or-flight” response and promote the parasympathetic “rest-and-digest” state. This neurological balancing can help reduce anxiety and improve overall well-being, which is crucial during recovery.
• Improving Body Awareness and Function: Recovery involves reconnecting with one’s body in a healthy way. Chiropractic care, combined with corrective exercises and soft tissue therapies like massage, helps patients improve their posture, movement patterns, and overall physical function. This empowerment can be a powerful psychological boost, providing a tangible sense of progress and control over one’s own health.

By integrating chiropractic care, we provide a non-pharmacological pathway to pain relief and improved neurological function, reducing one of the primary drivers of opioid use and supporting the body’s innate ability to heal.

Pharmacological Management: The Medications for OUD

Now we will delve into the specific medications used to treat OUD. To understand how they work, we must first understand how opioids interact with the brain.

Opioid Receptors and Their Binding Properties

Opioids produce their effects by binding to opioid receptors in the brain, spinal cord, and other parts of the body. The primary receptor involved in both pain relief and addiction is the mu-opioid receptor. Different substances bind to this receptor in different ways:

• Full Agonists: These substances bind to and fully activate the mu-opioid receptor. This produces the maximum opioid effect, including euphoria and, at high doses, dangerous respiratory depression. Examples include heroin, morphine, fentanyl, and methadone.
• Partial Agonists: These substances bind to the mu-opioid receptor but activate it only partially. This produces a limited opioid effect that hits a “ceiling.” Even with increasing doses, the effect plateaus, making it much safer in terms of overdose risk. The primary example is buprenorphine.
• Antagonists: These substances bind to the mu-opioid receptor but do not activate it. Instead, they block it, preventing any opioid agonist from binding and having an effect. If an agonist is already present, an antagonist will “bump” it off the receptor, rapidly reversing its effects. Examples include naloxone and naltrexone.

The risk of respiratory depression—the primary cause of death in an opioid overdose—is directly related to the level of mu-receptor activation. Full agonists have an unlimited potential for respiratory depression as the dose increases. Partial agonists carry a much lower risk because of their ceiling effect. Antagonists have no risk of respiratory depression.

Methadone

• Mechanism: Methadone is a long-acting full agonist. It occupies the mu-receptors, preventing withdrawal symptoms and reducing cravings without producing the intense, short-lived high of substances like heroin.
• Regulation: It is a Schedule II controlled substance, and due to its potential for misuse and its effect on cardiac rhythm, it can only be dispensed through federally certified Opioid Treatment Programs (OTPs), commonly known as methadone clinics.
• Clinical Considerations:

• • Side Effects: Common opioid side effects include constipation, sedation, dizziness, and sweating.
  • Serious Risks: The most significant risk is QTc prolongation, an electrical disturbance in the heart that can lead to fatal arrhythmias. This risk increases at doses over 100 mg/day, and EKG monitoring is often required. As a full agonist, it also carries a risk of respiratory depression.
  • Contraindications: Acute or severe asthma (due to respiratory risk) and paralytic ileus/GI obstruction (due to its effects on gut motility).

Buprenorphine

• Mechanism: Buprenorphine is a partial agonist at the mu-receptor and an antagonist at the kappa-receptor. It has two key properties that make it an ideal medication for office-based treatment:

1. 1. Ceiling Effect: As a partial agonist, it has a built-in safety mechanism. Its effects plateau, leading to a much lower risk of respiratory depression and overdose compared to full agonists.
   2. High Affinity: It binds very tightly to the mu-receptor, even more tightly than full agonists like heroin or fentanyl. This means it can block other opioids from having an effect.

1. Clinical Use and the Risk of Precipitated Withdrawal: Because buprenorphine has a higher affinity but lower intrinsic activity than full agonists, timing its initiation is critical. If a person has a full agonist (like heroin) in their system and takes buprenorphine, the buprenorphine will “kick” the heroin off the receptors and replace it. This causes a sudden drop in opioid effect, triggering a rapid and severe form of withdrawal known as precipitated withdrawal. To avoid this, we instruct patients to wait until they are in moderate withdrawal before taking their first dose. At that point, the buprenorphine will increase the opioid effect, bringing them up to the ceiling and alleviating their withdrawal symptoms.
2. Clinical Considerations:

• • Side Effects: Headache, constipation, nausea, and oral numbness (hypoesthesia) with sublingual formulations.
  • Serious Risks: While much lower than full agonists, there is still a risk of respiratory depression, especially when combined with other sedating substances like benzodiazepines or alcohol. Hepatotoxicity (liver injury) is a rare but serious risk.
  • Drug Interactions:

• Benzodiazepines: The FDA has issued guidance stating that the benefits of treating OUD with buprenorphine in a patient already taking benzodiazepines outweigh the risks. Withholding buprenorphine in this situation could lead the patient to use illicit fentanyl, which carries a much higher overdose risk. Close monitoring is essential.
• CYP3A4 Inhibitors/Inducers: Be mindful of drugs that affect the metabolism of buprenorphine. Inhibitors (like erythromycin, grapefruit juice) can increase its concentration, while inducers (like rifampin, St. John’s Wort) can decrease it.

Naloxone

• Mechanism: Naloxone is a pure opioid antagonist. It has a very high affinity for the mu-receptor and acts rapidly to reverse an opioid overdose by displacing the agonist and blocking the receptor.
• Use in Overdose Reversal: Naloxone is the life-saving drug used to reverse opioid overdoses. It is available as a nasal spray (e.g., NARCAN) and an injection.
• Critical Education Points:

• • Short Half-Life: Naloxone has a shorter half-life than most opioids. This means that after the naloxone wears off, the opioids still circulating in the person’s system can re-bind to the receptors and cause the overdose to return. It is absolutely critical to call 911 and seek emergency medical care after administering naloxone.
  • Co-Prescribing: As a standard of care, I co-prescribe naloxone to all my patients using opioids, and even to those using other illicit substances, because of the high risk of fentanyl contamination in the drug supply.
  • Training: Family and friends should be trained on how to recognize an overdose and administer naloxone. The person experiencing the overdose will be unable to administer it to themselves.

Naloxone is also included in many buprenorphine formulations (e.g., Suboxone). When taken sublingually as directed, the naloxone is not absorbed and has no effect. The combination was designed as a deterrent for intravenous misuse; if the tablet were to be crushed and injected, the naloxone would be activated and could precipitate withdrawal.

Naltrexone

• Mechanism: Naltrexone is an opioid antagonist that completely blocks the effects of opioids. It is also used for Alcohol Use Disorder, as it helps reduce cravings and the rewarding effects of alcohol.
• Clinical Use: Unlike buprenorphine or methadone, naltrexone does not provide any opioid effect. It is a good option for highly motivated individuals who have already completed detoxification.
• Formulations:

• • Oral (PO): Typically a 50 mg daily pill. Adherence can be a challenge.
  • Injectable (Vivitrol): A long-acting, 380 mg intramuscular injection given once a month. This formulation overcomes the daily adherence challenge.

• Clinical Considerations:

• • Opioid-Free Period: The patient must be completely free of all opioids for at least 7-10 days before starting naltrexone. Starting it sooner will cause severe precipitated withdrawal.
  • Liver Monitoring: Naltrexone can cause liver injury, so monitor liver enzymes. It is contraindicated in patients with acute hepatitis or liver failure.
  • Overdose Risk upon Discontinuation: A crucial counseling point is the risk of overdose if the patient relapses after stopping naltrexone. While on the medication, their opioid tolerance decreases. If they stop naltrexone and use their previous dose of opioids, it can be fatal.

Harm Reduction: A Pragmatic and Compassionate Approach

Harm reduction is a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use. It is a compassionate and evidence-based approach that accepts, as a starting point, that some individuals will continue to use drugs. The goal is to keep them alive and as healthy as possible.

Here are some key harm reduction strategies we should all be promoting:

• Naloxone Access and Education: This is the most important harm reduction tool. We need to ensure naloxone is widely available and that people know how to use it.
• Fentanyl Test Strips: These allow individuals to test their drug supply for the presence of fentanyl, a potentially life-saving piece of information that can influence their decision to use.
• Never Use Alone: We should encourage patients never to use drugs alone. The Never Use Alone Hotline (1-800-484-3731) is a vital resource where a person can call, provide their location, and stay on the line with a volunteer while they use. If they become unresponsive, the volunteer calls emergency services.
• Clean Needle Exchanges: Syringe service programs provide sterile injection equipment to reduce the transmission of bloodborne pathogens like HIV and Hepatitis C.
• Non-Judgmental Use of Urine Drug Screens: Instead of using drug screens as a punitive tool, we should use them as a harm reduction tool. If a patient’s screen is positive for fentanyl when they thought they were only using heroin, this is an opportunity for a non-judgmental conversation about the non-judgmental drug supply and the increased risk of overdose.
• Prescription Drug Monitoring Programs (PDMPs): These state-level databases help providers coordinate care and prevent dangerous combinations of prescriptions from multiple prescribers.
• Motivational Interviewing: As discussed, this approach respects the patient’s autonomy and works with their goals, which is the very essence of harm reduction.

Conclusion: A Call for Compassionate, Evidence-Based Care

The history of opioids and the ensuing public health crisis provide a crucial context for understanding the challenges our patients face. We have seen how stigma remains a formidable barrier to care, preventing individuals from seeking help and, at times, preventing providers from offering it. However, we have also seen a clear path forward.

We have effective, evidence-based treatments at our disposal. Medications for Opioid Use Disorder, when combined with behavioral therapies and a strong support system, can dramatically reduce mortality and help people reclaim their lives. Harm reduction strategies can keep people alive and engaged in care. By embracing person-first language and a compassionate, non-judgmental stance, we can help reduce the stigma that has caused so much harm.

At our clinic, we are committed to this integrated model of care. By combining Dr. Cardenas’s medical expertise, the functional and integrative approach I bring as both a DC and FNP, and our dedicated rehabilitation team, we address the whole person—their pain, brain chemistry, structural health, and personal goals. This is the future of treating Opioid Use Disorder, and it is a future filled with hope.

If you have any questions, please feel free to reach out. Thank you for taking the time to learn with me today.

References

• Centers for Disease Control and Prevention. (2021). S. Opioid Dispensing Rate Maps. [https://www.cdc.gov/drugoverdose/rxrate-maps/index.html](https://www.cdc.gov/drugoverdose/rxrate-maps/index.html)
• Kampman, K., & Jarvis, M. (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. [https://www.asam.org/quality-practice/guidelines-and-consensus-documents/npg](https://www.asam.org/quality-practice/guidelines-and-consensus-documents/npg)
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). The Guilford Press.
• Substance Abuse and Mental Health Services Administration. (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. [https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report](https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report)
• Volkow, N. D., & Collins, F. S. (2017). The role of science in addressing the opioid crisis. New England Journal of Medicine, 377(4), 391–394. [https://doi.org/10.1056/NEJMsr1706626](https://doi.org/10.1056/NEJMsr1706626)
• Wakeman, S. E., & Rich, J. D. (2018). Barriers to medications for addiction treatment: How to improve access and uptake. Journal of General Internal Medicine, 33(5), 589–591. [https://doi.org/10.1007/s11606-017-4279-3](https://doi.org/10.1007/s11606-017-4279-3)

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